IMAGE COPYRIGHT OF ABORTION RIGHTS CAMPAIGN
Maternal mental health matters not only because of the effects on the mother of mental distress, self-harm and the catastrophe of a completed suicide but also the devastating effects any and all of these can have on any children involved. During pregnancy in particular the incidence of mental health problems and suicidal ideas is high but the risk of suicide is lower than usual in the group as a whole. However, as maternal deaths in pregnancy from any cause (physical or mental) are rare in developed countries, suicide is still in the top 4 causes of maternal deaths.
Groups at higher risk of suicide are those with an unwanted pregnancy, particularly teenage mothers and those on low incomes. In its 2009 report on Maternal Mental Health, the UN’s World Health Organisation (WHO) has highlighted the increased risk of mental health problems in “unintended pregnancy especially among adolescent women”. They emphasise the further raising of risk from factors such as poverty and lack of support “in contexts in which there are strong, gendered role restrictions on women including lack of reproductive rights”. ‘Reproductive rights’ includes access to abortion services but also access to good quality obstetric, contraceptive and STD services as well as sex education and information. In his 2011 journal article ‘Suicidal Mothers’, Salvatore Gentile concluded that: “Psychosocial factors which may also contribute to increase the rate of maternal suicide attempts during pregnancy are teen age, unplanned pregnancy, unmarried status or recent divorce, unemployment, and difficult access to safe abortion service.”
It has also been shown that suicide in pregnancy (and the year after birth, known as the ‘puerperium’) has become much less common with access to abortion services. Professor R.E. Kendall summarised this conclusion in the title of his succinct 1991 review in the British Medical Journal: ‘Suicide in pregnancy and the puerperium, much rarer now thanks to contraception, abortion and less punitive attitudes’. It is therefore clear from this peer-reviewed research that restricting access to abortion, that is, denying women ‘the right to choose’, raises the risk of suicide in pregnancy.
Abortion services are frequently smeared with the notion that choosing an abortion increases the risk of mental health problems and even suicide. This false conclusion is a misreading (often deliberate and repeated) of the positive correlation between those who have had abortions and mental health problems. That there is a higher incidence of mental health problems in people who have had abortions is undisputed. However ‘correlation is not causation’ and when unwanted pregnancy and factors such as previous mental health or trauma such as rape are taken into account the association disappears. It would be very good if this association was used as a marker to identify a group at risk, that is as a ‘risk indicator’ and used to facilitate access to mental health services. A good example of prejudice clouding judgement in this way is the observation that LGBT individuals are at higher risk of mental health problems. One conclusion, by the same fundamentalist Christians who populate the anti-choice lobby, is that homosexual or transgendered people should be ‘cured’ from this obvious ‘disease’. The modern psychiatric approach, based on evidence, has been to reject the notion of homosexuality or transgender as diseases by identifying the high incidence of bullying and discrimination as causative factors for mental health problems in this group.
Repeatedly, when the allegation (that abortion leads to mental health problems or suicide) is systematically and scientifically investigated, it is found to be false. The American Psychological Association in 2006, under intense scrutiny from the anti-choice lobby, found there was no evidence that choosing to have an abortion raised the risk of mental health problems. Where there is choice of abortion services there is no increase in suicide (or mental health problems) caused by choosing an abortion.
The insistence on misinterpreting the data (most recently by the Irish Bishops, Irish Times report on March 7th) to conclude abortion is causative or a ‘risk mediator’ leads to the false conclusion that abortion should be restricted as an option. As we have seen the psychiatric research to date in fact supports entirely the opposite conclusion. Restricting choices raises the risk of suicide. Furthermore, reducing the risk of suicide includes non-directive counselling in unwanted pregnancy and, where the woman gives her informed consent to choose abortion, facilitating access to abortion services including proper aftercare therefore reduces the risk of suicide.
In Ireland abortion, and even access to information on abortion, is heavily restricted with a criminal sanction confirming the ‘punitive attitude’ Prof Kendall referred to over 20 years ago. Women are forced to travel, usually alone or with a very restricted support network because of the costs of travel. As a result, in this Irish context, the restriction of access to abortion services is mediated by restrictions on travel. The following groups whose ability to travel is compromised are therefore at an increased risk of restricted access to abortion and hence increased risk of suicide:
Women too sick to travel
Adolescents and young women
Women with young children
Women with Disabilities
Women with no or low incomes
Women whose pregnancy, involves a fatal foetal malformation
Women pregnant as the result of rape or child sexual abuse.
Some women will have multiple risk factors but also some factors involve multiple risks for suicide eg low income is a risk for mental illness, unwanted pregnancy and inability to travel.
The obvious solution to these risk factors is to end the unnecessary, dangerous, and, for the most part, ineffective restrictions on abortion services. This is the very successful approach taken in Canada for the last 25 years. Abortion rates are relatively low (we have no idea of the rate in Ireland) and abortion is subject to healthcare ethics not criminal law; just like every other medical service. It is an ongoing absurdity that pregnant women are in some way considered to be exceptions to the usual rules of capacity to make a decision. Capacity is best treated as being present as a default unless there are grounds to believe otherwise. What are these grounds? That the patient is a woman?
It seems likely however that, instead of the Canadian model, emergency legislation is proposed to deal with the risk to only some of those who can’t travel. Certifying a risk to the life as opposed to the health of pregnant women has put an emphasis on suicide that shows little respect for either crisis pregnancy or suicide. Anti-choice proponents have emphasised that ‘Abortion is not a treatment for suicide’ and ignored the fact that there is no ‘treatment’ for suicide. Abortion for those who choose it with proper supports is as much a treatment for suicide as blood pressure tablets are a ‘treatment’ for a heart attack. Both lower the impact of a relevant risk factor; that is, the distress of an unwanted pregnancy and blood pressure respectively. The ‘treatment’ for unwanted pregnancy is ‘Non-directive counselling’ and the ‘treatment’ for suicide is risk-reduction which can include facilitating abortion for unwanted pregnancy following non-directive counselling, with informed consent.
In summary therefore in the psychiatric aspects of abortion it is important to stress that unwanted pregnancy is the relevant risk factor and that children and young people are at particular risk. Restriction of access to abortion increases suicide risk and supported choice reduces suicide risk. While there is no medical need for a special legal framework for abortion, doctors are perfectly capable of certifying the need to support a woman’s choice of abortion services to reduce her risk of mental health problems and suicide.
Doctors for Choice is an organisation of doctors who wish to promote choice in reproductive healthcare. This means advocating for informed consent as the basis for decision making within the doctor-patient relationship.